Meeting/Conference > District of Columbia Meeting/Conference

Diagnostic error reduction continues to gain momentum in the research and frontline patient safety communities. This annual conference will focus on the theme, "Shaping Policy, Improving Practice" to discuss physical examination, patient partnership, and political advocacy as strategies to improve diagnosis. Featured speakers include Dr. Shantanu Agrawal, Dr. Helen Burstin and Dr. David Newman-Toker.

Meeting/Conference > Missouri Meeting/Conference

Second victims are clinicians who experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. This workshop will explore strategies that addresses individual stages of recovery and trains peers to participate in that process. Sue Scott will lead the session.

Meeting/Conference > Massachusetts Meeting/Conference

This multidisciplinary conference will offer insights from safety leaders about applying strategies and guidelines to quality and safety improvement in the acute care setting. The session will cover various topics of interest to professionals who work in the field, including radiation safety, care redesign, and leadership skill development.

Meeting/Conference > Maryland Meeting/Conference

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

Meeting/Conference > Government Resource

Rockville, MD; Agency for Healthcare Research and Quality: September 28, 2016.

Research is increasingly focusing on diagnostic errors and strategies to reduce them. This conference explored the science behind diagnosis and discuss the research, tactics, and tools needed to enhance diagnostic performance.

Morbidity and mortality ("M&M") conferences are standard components of training programs and are mandated by the Accreditation Council for Graduate Medical Education. Despite their ubiquity, a prior study of internal medicine and surgery conferences found that errors were discussed infrequently (particularly in internal medicine); thus, housestaff were being denied an important patient safety learning opportunity. In this study, researchers interviewed conference leaders from 12 departments at an academic hospital and found that only a minority identified patient safety and quality improvement as an important learning objective for the conference. Conferences generally did not include recommended elements for analyzing and learning from errors (e.g., assigning responsibility for follow-up). A prior article described how one residency program redesigned M&M to focus on patient safety and learning from errors.

Journal Article > Study

The investigators conducted a survey to inform the implementation of a nonpunitive medication error reporting policy and educational workshop. A comparison to post-initiative findings revealed that staff perception of reporting improved after the educational initiative.

Audiovisual > Audiovisual Presentation

Experts participating in this event evaluated the progress made since the release of To Err is Human, and the steps needed to improve safety moving forward. This page includes archived video, transcripts, and presentation slides from the event as well as participant biographies.

Meeting/Conference > Government Resource

The goals of this workshop included sharing new knowledge, tools, and strategies for states to use in improving their patient safety programs and policies. The Agency for Healthcare Research and Quality's (AHRQ) User Liaison Program (ULP) developed the workshop to disseminate health services research findings for practical use through interactive sessions.